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The role of the sports cardiologist has evolved into an essential component of the medical care of athletes. In addition to the improvement in health outcomes caused by reductions in cardiovascular risk, exercise results in adaptations in cardiovascular structure and function, termed exercise-induced cardiac remodeling. As diagnostic modalities have evolved over the last century, we have learned much about the healthy athletic adaptation that occurs with exercise. Sports cardiologists care for those with known or previously unknown cardiovascular conditions, distinguish findings on testing as physiological adaptation or pathological changes, and provide evidence-based and "best judgment" assessment of the risks of sports participation. We review the effects of exercise on the heart, the approach to common clinical scenarios in sports cardiology, and the importance of a patient/athlete-centered, shared decision-making approach in the care provided to athletes., Competing Interests: Funding Support and Author Disclosures Dr Martinez has served as a consultant for Major League Soccer and Bristol Myers Squibb. Dr Kim has received research funding through the National Institutes of Health; and has received compensation as team cardiologist for the Atlanta Falcons. Dr Bunch has received research grants from Boehringer Ingelheim, Boston Scientific, and Altathera (no personal compensation). Dr Baggish has received support from the National Institute of Health/National Heart, Lung, and Blood Institute, the National Football League Players Association, and the American Heart Association; and receives compensation for his role as team cardiologist from the U.S. Olympic Committee/U.S. Olympic Training Centers, U.S. Soccer, U.S. Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Aortic dilatation is frequently encountered in clinical practice among aging endurance athletes, but the distribution of aortic sizes in this population is unknown. It is additionally uncertain whether this may represent aortic adaptation to long-term exercise, similar to the well-established process of ventricular remodeling., Objective: To assess the prevalence of aortic dilatation among long-term masters-level male and female athletes with about 2 decades of exercise exposure., Design, Setting, and Participants: This cross-sectional study evaluated aortic size in veteran endurance athletes. Masters-level rowers and runners aged 50 to 75 years were enrolled from competitive athletic events across the United States from February to October 2018. Analysis began January 2019., Exposures: Long-term endurance exercise., Main Outcomes and Measures: The primary outcome was aortic size at the sinuses of Valsalva and the ascending aorta, measured using transthoracic echocardiography in accordance with contemporary guidelines. Aortic dimensions were compared with age, sex, and body size-adjusted predictions from published nomograms, and z scores were calculated where applicable., Results: Among 442 athletes (mean [SD] age, 61 [6] years; 267 men [60%]; 228 rowers [52%]; 214 runners [48%]), clinically relevant aortic dilatation, defined by a diameter at sinuses of Valsalva or ascending aorta of 40 mm or larger, was found in 21% (n = 94) of all participants (83 men [31%] and 11 women [6%]). When compared with published nomograms, the distribution of measured aortic size displayed a rightward shift with a rightward tail (all P < .001). Overall, 105 individuals (24%) had at least 1 z score of 2 or more, indicating an aortic measurement greater than 2 SDs above the population mean. In multivariate models adjusting for age, sex, body size, hypertension, and statin use, both elite competitor status (rowing participation in world championships or Olympics or marathon time under 2 hours and 45 minutes) and sport type (rowing) were independently associated with aortic size., Conclusions and Relevance: Clinically relevant aortic dilatation is common among aging endurance athletes, raising the possibility of vascular remodeling in response to long-term exercise. Longitudinal follow-up is warranted to establish corollary clinical outcomes in this population.

Purpose of Review: This review summarizes several issues at the forefront of recent controversies involving the appropriate exercise dose including epidemiologic data describing mortality trends in those who engage in high levels of physical activity and recent observational data suggesting adverse cardiovascular outcomes among long-term endurance athletes., Recent Findings: The benefits of habitual and moderate levels of exercise on cardiovascular disease outcomes in the general population have been well established. However, recent data have questioned whether higher doses of physical and athletic activity are associated with adverse cardiovascular outcomes. Specifically in regard to adverse cardiovascular outcomes, the evidence and limitations of the available data associating veteran endurance athletes with an increased risk of atrial fibrillation, exercise-induced arrhythmogenic cardiac remodeling, and accelerated coronary atherosclerosis will be discussed. This review will also provide a conceptual framework in the context of the clinical management of athletic patients and will highlight key areas of future research that may resolve many of these controversial issues.

Hypertension is a leading cardiovascular risk factor in athletes. Sport-specific behaviors including nonsteroidal anti-inflammatory use, stimulant use, and unhealthy diets may promote hypertension among athletes. Strength-trained athletes may be more susceptible to hypertension than endurance-trained athletes, although this may, in part, be due to body size differences and the more potent antihypertensive effects of aerobic exercise. With confirmed hypertension, young athletes require secondary hypertension evaluation while older athletes require full cardiovascular risk stratification. Calcium channel blockers and renin-angiotensin-system inhibitors are often preferred pharmacotherapy agents. Further selection of antihypertensives must include consideration of potential side effects and legality in specific sports. [ABSTRACT FROM AUTHOR]

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Cardiac disease can present in the training room through three portals: the preparticipation history and physical may identify concerns, the athlete may present with symptoms, or screening modalities may demonstrate abnormal findings. Training-related cardiovascular remodeling can mimic real disease, therefore providers must be able to separate the two. Sports medicine providers must be knowledgeable in how these present and how to care for these concerns to ensure proper care and avoid unnecessary restrictions of athletes. This article discusses 10 common cardiac concerns that can arise in the training room. [ABSTRACT FROM AUTHOR]

Purpose: We sought to explore the association between the spinal cord injury (SCI) level on the cardiac structure and the function observed in elite para-cyclists. Methods: Cross-sectional echocardiographic data from 44 elite SCI hand cyclists (39.8 ± 9 yr, 68% male/32% female) stratified by the level of SCI (cervical, N= 9; T1-T5, N= 10; below T5, N= 25) and 19 non-SCI blind/visually impaired (BVI) tandem cyclists (32.4 ± 7 yr, 58% male/42% female) were analyzed before the initiation of international competition. Results: Compared with non-SCI BVI cyclists, cervical SCI para-cyclists were observed with lower indexed left ventricular (LV) mass (99.6 ± 12 vs 125 ± 20 g-m, P = 0.01), posterior wall thickness (4.5 ± 0.3 vs 5.8 ± 0.7 mm⋅m-2, P < 0.001), interventricular septal wall thickness (4.8 ± 0.5 vs 5.7 ± 0.7 mm⋅m-2; P = 0.03), and left atrial volume (21 ± 3.5 vs 28 ± 7 mL⋅m-2; P = 0.02). In multivariable analyses, cervical SCI was independently associated with decreased LV wall thickness [interventricular septum (β = -0.67, P = 0.01), posterior wall (β = -0.98, P = 0.001)], decreased LV mass (β = -21, P < 0.001), and decreased left atrial volume index (β = -6.9, P = 0.001) compared with other levels of SCI and non-SCI BVI cyclists. There were no differences in ventricular function among any of the athlete groups. Conclusion: Compared with para-cyclists with lower levels of SCI, the athletes with cervical SCI demonstrate attenuated cardiac size and concentric LV hypertrophy. [ABSTRACT FROM AUTHOR]

Background--Hypertension, a strong determinant of cardiovascular disease risk, has been documented among elite, professional American-style football (ASF) players. The risk of increased blood pressure (BP) and early adulthood hypertension among the substantially larger population of collegiate ASF athletes is not known. Methods and Results--We conducted a prospective, longitudinal study to examine BP, the incidence of hypertension, and left ventricular remodeling among collegiate ASF athletes. Resting BP and left ventricular structure were assessed before and after a single season of competitive ASF participation in 6 consecutive groups of first-year university athletes (n= 113). ASF participation was associated with significant increases in systolic BP (116±8 versus 125±13 mmHg; P<0.001) and diastolic BP (64±8 mmHg versus 66±10 mmHg; P<0.001). At the postseason assessment, the majority of athletes met criteria for Joint National Commission (seventh report) prehypertension (53 of 113, 47%) or stage 1 hypertension (16 of 113, 14%). Among measured characteristics, lineman field position, intraseason weight gain, and family history of hypertension were the strongest independent predictors of postseason BP. Among linemen, there was a significant increase in the prevalence of concentric left ventricular hypertrophy (2 of 64 [3%] versus 20 of 64 [31%]; P<0.001) and change in left ventricular mass correlated with intraseason change in systolic BP (R=0A6, P<0.001). Conclusions--Collegiate ASF athletes may be at risk for clinically relevant increases in BP and the development of hypertension. Enhanced surveillance and carefully selected interventions may represent important opportunities to improve later-life cardiovascular health outcomes in this population. [ABSTRACT FROM AUTHOR]

The article presents research on how Interleukin-13 drives metabolic conditioning of muscle to endurance exercise. It discusses the increased metabolic activity of contracting skeletal muscle elicits an integrated response involving multiple tissues and signaling pathways to cope with increased energy and oxygen demands.